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European Union legislation (EU 2011) refers to sugars as 'all monosaccharides and disaccharides present in food, but excludes polyols', while foods with no added sugars are defined as foods without 'any added monosaccharides or disaccharides', or without 'any added food containing monosaccharides or disaccharides which is used for its sweetening purposes' (EC 2008,EU 2011)a.

The European Food Safety Authority (EFSA), in its scientific opinion on Dietary Reference Values for carbohydrates and dietary fibre (EFSA 2010a), refers to added sugars as 'sucrose, fructose, glucose, starch hydrolysates (glucose syrup, high-fructose syrup) and other isolated sugar preparations used as such or added during food preparation and manufacturing' (not including the sugars present in unsweetened fruit juice or honey as added sugars), and total sugars as the sum of added sugars and endogenous sugars present in fruits, vegetables, cereals, as well as lactose in milk products. The United States (US) Institute of Medicine (IoM) provides a similar definition for added sugars (IOM 2006).

For the World Health Organization (WHO 2015), the term sugars includes intrinsic sugars, which are those incorporated within the structure of intact fruit and vegetables; sugars naturally present in milk (lactose and galactose); and free sugars, which are 'monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates'. The main difference between the EFSA and WHO definitions is that the WHO 'free sugars' covers not only all sugars added to foods during manufacture or by the consumer, but also those present in fruit juice and honey or syrups.

In the US, the Food and Drug Administration (FDA 2017), states that 'the definition of added sugars includes sugars that are either added during the processing of foods, or are packaged as such, and include sugars (free, mono- and disaccharides), sugars from syrups and honey, and sugars from concentrated fruit or vegetable juices that are in excess of what would be expected from the same volume of 100 percent fruit or vegetable juice of the same type. The definition excludes fruit or vegetable juice concentrated from 100 percent fruit juice that is sold to consumers (e.g. frozen 100 percent fruit juice concentrate) as well as some sugars found in fruit and vegetable juices, jellies, jams, preserves, and fruit spreads'.

For the purposes of this Brief, the term sugars, added sugars, total sugars, intrinsic sugars and free sugars and will refer to the definitions provided above, while the term 'sugar' will refer to sucrose exclusivelyb.

Sugars belong to the family of carbohydrates. In the EU legislation (EU 2011), the term 'carbohydrates' refers to 'any carbohydrate which is metabolised by humans, and includes polyols' (see 1.2). Carbohydrates can be single unit molecules, but can also be made up of several units linked together by a variety of chemical bonds. Major dietary carbohydrates, including sugars, can be classified as described in Table 1.

In the EU (EC 2008,EU 2011) sweeteners are referred to as food additive substances used to 'impart a sweet taste to foods or in table-top sweeteners'. Table-top sweeteners 'shall mean preparations of permitted sweeteners, which may contain other food additives and/or food ingredients and which are intended for sale to the final consumer as a substitute for sugars'.

In order to be included in the list of EU approved food additives, and in addition to the general requirements of food additives, sweeteners must serve one or more of these purposes: i) 'replacing sugars for the production of energy-reduced food, non-cariogenic food or food with no added sugars' or ii) 'replacing sugars where this permits an increase in the shelf life of the food'e. Following the above definition, for the purposes of this Brief, the term 'sweeteners' will refer to those non-nutritive (or low caloric) food additives that are approved for use as sugar replacers in the EU and are reported in Table 3.

Sweeteners can be of two categories: high-intensity sweeteners, which are substances with an intense sweet taste and with no energy value that are used to replace sugars in foods (EFSA 2011)f and polyolsd, defined as 'alcohols containing more than two hydroxyl groups', which are low calorie sugar replacers, but which can also exert other technological functions in food and can be used for purposes other than sweetening.

Common monosaccharides include glucose, fructose and galactose, while the main dietary disaccharides are sucrose (consisting of glucose and fructose) and lactose (consisting of glucose and galactose). The sources of these are described in Table 2 and include plants, especially fruits and vegetables where most mono- and disaccharides are intrinsically occurring. In addition, sugars are added to foods to impart a sweet taste, during cooking, table top use or in processed foods and beverages; this includes honey, molasses and various syrups such as isoglucose, or malt, corn or sugar beet syrups.

Table 2: Main dietary sugars (mono- and disaccharide carbohydrates) and their sources

The predominant disaccharide, sucrose is naturally present in large quantities in sugar cane and sugar beet, as well as in many vegetables, roots and fruits. Major dietary sources include, apart from table-top use and cooking, a variety of processed foods and beverages sweetened with sugar, e.g. soft drinks and juicesa, sports and energy drinks as well as confectionary products, sweet and savoury snacks, sweet spreads and jams, dairy products and ice-cream. In the body, sucrose is metabolised into glucose and fructose.

Lactose

Another major disaccharide, predominantly found naturally in milk and dairy products. In the body, lactose is hydrolysed into galactose and glucose.

Maltose/Trehalose

Maltose, (made up from 2 molecules of glucose) is the least common of the three major disaccharides, and is found in nature in small amounts (e.g. in barley, wheat, germinating grain). Major dietary sources include beer, cereals, cooked sweet potatoes, pasta and sweetened processed products. Trehalose is also made from two glucose molecules; the difference with maltose lies in the configuration of the chemical bond between the glucose molecules. It is found in yeast products, mushrooms and crustaceans.

Glucose

Fructose

Galactose

These monosaccharides occur naturally in small amounts in fruits, vegetables and plant juices. Apart from the consumption of the above, dietary sources include honey and syrups. Free galactose is rare in foods, except in fermented and lactase-hydrolysed milks.

a The addition of sugars is not authorised in fruit juices, fruit juice from concentrate, concentrated fruit juice, water extracted fruit juice, and dehydrated/powdered fruit juice, and is only allowed in fruit nectars under specific requirements (EU 2012).

In the EU, Regulation (EU) 1169/2011 (EU 2011) on food information to consumers requires mandatory nutrition declaration for sugars, under carbohydrates (stating amount of g per 100 g of product), in prepacked foods. For labelling purposes, the reference intake for sugars of an average adult (8400 kJ/2000 kcal) is 90 g/day. In addition, the same regulation states that, in conversion factors for the calculation of energy, carbohydrates (including sugars) have an energy value of 4 kcal/g.

Under Regulation (EU) 1924/2006 (EC 2006) for health and nutrition claims made on foods, the following sugars-related nutrition claims are permitted:

Sugar-free claims, 'may only be made where the product contains no more than 0,5 g of sugar per 100 g or 100 ml'.

With no added sugars claims 'may only be made where the product does not contain any added mono- or disaccharides or any other food used for its sweetening properties. If sugars are naturally present in the food, the following indication should also appear on the label: CONTAINS NATURALLY OCCURRING SUGARS'.

Low sugars claims 'may only be made where the product contains no more than 5g of sugar per 100 g for solids or 2,5 g of sugar per 100 ml for liquid'.

In the EU, in general, if a food additive belongs to the category/functional class 'sweetener' it must be designated by the name of that category (i.e., 'sweetener'), followed by its specific name or, if appropriate, E number on the food packaging (EC 2008,EU 2011).

Regulation (EU) 1169/2011 (EU 2011) on food information to consumers requires any food containing a sweetener(s) authorised pursuant to Regulation (EC) No 1333/2008 (EC 2008,EU 2011) (i.e. the sweeteners referred to in this Brief) to carry 'with sweetener(s)' as a statement that shall accompany the name of the food. Foods containing both an added sugar or sugars and a sweetener or sweeteners authorised pursuant to Regulation (EC) No 1333/2008 shall carry the statement 'with sugar(s) and sweetener(s)' as a statement that shall accompany the name of the food.

The sales description of a table-top sweetener shall include the term ‘…-based table-top sweetener', using the ame(s) of the sweetener(s) used in its composition. The labelling of a table-top sweetener containing polyols and/or aspartame and/or aspartame-acesulfame salt shall bear the following warnings: for polyols: ‘excessive consumption may induce laxative effects’, and for aspartame/aspartame-acesulfame salt: ‘contains a source of phenylalanine’.Table-top sweeteners are exempted from mandatory nutrition declaration (EU 2011).

Foods containing aspartame/aspartame-acesulfame salt authorised pursuant to Regulation (EC) No 1333/2008 shall be accompanied by a statement 'contains aspartame (a source of phenylalanine)' on the label, if the substance is designated in the list of ingredients only by its E number; in cases where aspartame/aspartame-acesulfame salt is designated in the list of ingredients by its specific name, the statement appearing on the label shall be 'contains a source of phenylalanine'.

Foods containing more than 10% added polyols authorised pursuant to Regulation (EC) No 1333/2008 (EC 2008,EU 2011) shall be labelled with the particular 'excessive consumption may produce laxative effects'. In addition, Regulation (EU) 1169/2011 (EU 2011) states that the energy value to be declared in the nutrition declaration shall be calculated using the conversion factors of 10 kJ/g - 2,4 kcal/g for polyols and 0 kJ/g - 0 kcal/g for erythritol. The unit of measurement to be used in the nutrition declaration for mass of polyols is grams (g), and the order of presentation of the information, as appropriate, is indicated in Regulation (EU) 1169/2011.

As regards nutrition claims foreseen under Regulation (EU) 1924/2006 (EC 2006), some apply to table-top sweeteners, as is the case of food low in energy and energy-free food. Two sweetener related health claims have been approved for use under specific conditions (EU 2012), following EFSA opinions (EFSA 2011,EFSA 2011); both relate to the use of intense sweeteners and polyols as sugar replacers (consumption of foods/drinks containing intense sweeteners and/or polyols instead of sugar contributes to the maintenance of tooth mineralisation and to reduction of post-prandial glycaemic responses compared to sugar- containing foods/drinks see also Table 5).

A number of national or international institutions have recently examined the potential impact of sugars consumption on health, focusing mainly on effects on body weight management, Type 2 Diabetes mellitus (T2DM), cardiovascular parameters such as blood glucose, pressure, lipids, cholesterol and dental health. The statements or opinions of these institutions, as well as the strength of the supporting evidence, are shown in Table 4. Sugar Sweetened Beverages (SSBs) consumption is high in many parts of the world and is considered to significantly contribute to added sugar intake (WHO 2018, CDC website, EC 2018). A considerable amount of evidence presented in this brief includes SSBs.

Table 4: Health effects related to sugars intake as described by food- and health-related organisations.

'Concerning…blood pressure, in the short- and medium-term intervention studies, deleterious metabolic effects of sugars were observed, in the case of very high consumption and/or consumption associated with an excess energy intake. However, the long-term impact of these changes on the occurrence of pathologies remains unknown'.

'There is possible evidence that there is no association between long-term intake of fructose or sucrose and blood pressure increase'.

'There is possible evidence that there is no association between the intake of sugar-sweetened beverages and the risk of hypertension. This judgement is based on 1 cohort study only, but is confirmed by the judgement of the individual components of sweetened beverages like fructose and sucrose'.

'…evidence suggests that excessive fructose intake results in increased blood pressure in children and young adult'.

'…evidence suggests that added sugars are a source of excess fructose and that reduction of fructose from added sugars is likely to decrease uric acid, possibly improving blood pressure in children. However, further research on this topic is needed to test whether a reduction in added sugars results in improved blood pressure in children'.

Although some evidence exists that high intakes (>20 E%) of sugars may increase serum triglyceride and cholesterol concentrations, the available data are not sufficient to set an upper limit for (added) sugar intake.

'epidemiological studies indicate a hypertriglyceridemia effect of sugars provided in the form of sugar-sweetened beverages, but these data do not show a specific effect, independent of total energy intake'.

'The effect of sugars containing fructose (sucrose, HFCS), the respective roles of excess energy or sugar intake per se, and the effect of co-ingestion of glucose and fructose, are still poorly understood. But in the intervention studies, daily intakes of fructose above 50 g/d can lead to an increase in fasting and/or post-prandial blood triglycerides'.

Based on limited evidence, no significant effect is demonstrated for diets differing in the proportion of sugars on fasting total cholesterol, fasting low density lipoprotein (LDL) or high density lipoprotein (HDL) cholesterol concentration, or fasting triacylglycerol concentration.

'there is insufficient evidence regarding the influence of increased intake of mono- or disaccharides on the plasma levels of total and/or LDL cholesterol'.

'there is insufficient evidence regarding the influence of increased intake on mono- or disaccharides on the plasma levels of HDL cholesterol'.

'the evidence is judged as probable that there is no association between a fructose intake of < 100 g/day and the fasting plasma triglyceride concentration as well as between a fructose intake of < 50 g/day and the postprandial plasma triglyceride concentration, respectively'.

'There is convincing evidence that with higher fructose intake of up to 350 g/day, the fasting plasma triglyceride concentration increases'.

'The evidence regarding the effects of other mono- and disaccharides on plasma triglycerides is insufficient'.

'Although there is some evidence that high intakes (>20 E%) of sugars may increase serum triglyceride and cholesterol concentrations, and that >20 to 25 E% might adversely affect glucose and insulin response, the available data are not sufficient to set an upper limit for (added) sugar intake'.

'Concerning glucose homeostasis and insulin sensitivity, the studies indicate that only a very large increase in fructose intake, of around 80 g/d, leads to a decrease in hepatic sensitivity to insulin. This effect, however, is modest and is not accompanied by a clinically significant increase in fasting blood glucose'.

'A limited number of epidemiological cohort studies indicate an increase in the incidence of diabetes in high consumers of sugar-sweetened beverages; however this is in part linked to the weight status'.

For those pathologies where weight gain and obesity are established risk factors, in particular for T2DM, the contribution of sugars to excess energy intake must not be overlooked.

Based on limited evidence, there is no effect of sugars consumption on fasting blood glucose concentration and blood insulin concentrations.

Based on limited evidence, there is 'no consistent evidence of an association between diets differing in the proportion of sugars in relation to incidence of type 2 diabetes mellitus'. Sucrose and fructose were also individually examined with same findings.

Based on moderate evidence, an association was found between greater sugars-sweetened beverage (SSB) soft-drink consumption and higher incidence of type 2 diabetes mellitus, while there was insufficient that included fruit juices. The association direction indicates that 'greater consumption of SSBs is detrimental to health'.

'Strong evidence shows that higher consumption of added sugars, especially sugar-sweetened beverages, increases the risk of type 2 diabetes among adults and this relationship is not fully explained by body weight'.

For those pathologies where weight gain and obesity are established risk factors, in particular for endometrial cancer and breast cancer, the contribution of sugars to excess energy intake must not be overlooked.

'a cause and effect relationship has not been established between total sugar intake and body weight gain'.

'the evidence relating high intake of sugars (mainly as added sugars), compared to high intakes of starch, to weight gain is inconsistent for solid foods'.

'However, there is some evidence that high intakes of sugars in the form of sugar-sweetened beverages might contribute to weight gain. The available evidence is insufficient to set an upper limit for sugars based on their effects on body weight. Evidence on the relationship of sugar-sweetened beverages and body weight should be considered when developing food-based dietary guidelines'.

'Weight gain is related to an excess energy intake. Sugars and particularly sugar-sweetened beverages contribute to this excess energy intake'.

'Concerning the effect of sugars on adiposity and the distribution of body fat, the data are too limited to reach any conclusion'.

'sugars, and more particularly in liquid form (sodas, nectars, fruit juices produced from concentrates, fresh fruit juices, smoothies, etc.) contribute to weight gain, with a convincing level of evidence'.

Based on adequate evidence, sugars consumption has an effect on energy intake; the direction of the effect demonstrates that greater consumption of sugars is detrimental to health (relevant in free living individuals not subject to energy restriction).

In cohort studies, there is limited and conflicting evidence on the relationship between SSBs consumption and Body Mass Index (BMI).

In cohort studies, 'overall there is no consistent evidence of a significant change in body fat amount or distribution with sugars-sweetened beverage consumption assessed in childhood or adolescence' (limited evidence).

In randomised control trials (RCTs), and based on limited evidence, SSBs consumption has an effect on BMI; 'the direction of the effect demonstrates that greater consumption of SSBs is detrimental to health.'

'The evidence regarding the relevance of monosaccharides for the risk of obesity is insufficient'

The evidence regarding the relevance of sucrose or added sugar, respectively, for the risk of obesity in children, adolescents and adults is insufficient.

'The available cohort and intervention studies regarding adults mainly show that a higher consumption of sugar-sweetened beverages is accompanied by an increased risk of obesity. Therefore, the respective evidence is judged as probable'.

'The overall evidence regarding an increased risk of obesity due to higher consumption of sugar-sweetened beverages in children and adolescents is only judged as possible'.

'The evidence regarding an increased risk of obesity especially in children and adolescents with initially already increased BMI or already existing overweight is also judged as possible'.

'children and adolescents who have high intakes of dietary sugars (specifically from SSBs and added sugars) tend to have higher daily energy intakes compared with similar populations with lower intakes of dietary sugars'.

In children, 'higher SSB and added sugars intake has been strongly linked to excess weight gain and an increased risk of obesity'.

'Strong and consistent evidence shows that intake of added sugars from food and/or sugar sweetened beverages are associated with excess body weight in children and adults'; reduction of added sugars and/or SSBs in the diet reduces body mass index in both children and adults.

'a cause and effect relationship has been established between the consumption of sugar-containing foods/drinks at an exposure frequency of four times daily or more and an increased tooth demineralisation'

available data do not allow the setting of an upper limit for sugars on the basis of a risk reduction for dental caries, 'as caries development related to consumption of sucrose and other cariogenic carbohydrates does not depend only on the amount of sugar consumed, but it is also influenced by various other lifestyle factors…'.

Moderate quality evidence from cohort studies suggests a positive association between levels of free sugars intake and dental caries; higher rates of caries when free sugars intake exceeds 10% of total energy. In three population studies with very low quality of evidence, lower levels of caries development were observed with approx. free sugars intake of 5%.

Based on moderate evidence, there is an association between amount of sugars consumed and dental caries in mixed and permanent dentition; 'The direction of the association indicates that greater consumption of sugars is detrimental to oral health'. No significant association reported between the frequency of sugars consumption and the risk of developing dental caries in mixed and permanent dentition.

Adequate evidence for an association between the amount and frequency of SSBs and detriment to deciduous dentition. 'The direction of the association indicates that greater consumption of sugars sweetened beverages is detrimental to oral health'.

Amount and frequency of consumption of sugar containing foods and/or confectionary is associated with dental caries. 'The direction of the association indicates that greater consumption of sugars containing foods and/or sugars confectionery is detrimental to oral health'. For deciduous dentition there is limited evidence, while for mixed and permanent dentition the evidence is moderate.

'The DGAC concurs with the World Health Organization's commissioned systematic review that moderate consistent evidence supports a relationship between the amount of free sugars intake and the development of dental caries among children and adults. Moderate evidence also indicates that caries are lower when free sugars intake is less than 10 percent of energy intake'.

'Observed negative associations between added sugar intake and micronutrient density of the diet are mainly related to patterns of intake of the foods from which added sugars in the diet are derived rather than to intake of added sugars'.

'For the risk of non-alcoholic fatty liver disease, a small number of intervention studies show that an excess energy intake, in particular in the form of fructose, increases the concentration of intrahepatic lipids in healthy subjects. The epidemiological data are, however, insufficient to assess the role of sugars in the occurrence of this pathology'.

'the introduction of added sugars during infancy appears to be particularly harmful and should be avoided'.

The safety of sweeteners examined in this Brief has been extensively reviewed and (re)evaluated by a variety of competent authorities, including the European Food Safety Authority (EFSA webpage) and other national authorities such e.g. as the US Food and Drug Administration (FDA webpage). All sweeteners discussed here are approved and considered safe to use in the EU. The focus is therefore on nutrition and diet related health effects. For sweeteners, the main areas of focus refer to their use as sugars replacers and their effects on weight gain loss or maintenance, cardiovascular parameters, such as blood glucose and lipids, T2DM, dental health, and other categories such as appetite or gastrointestinal health (Table 5).

Table 5: Health effects related to sweeteners intake as described by food- and health-related organisations

Note that each institution may refer to sweeteners using different terminology.

'The majority of observational studies showed no effects on lipid profile related to intense sweeteners. Two studies reported that replacing sugars with aspartame reduced plasma concentrations of triglycerides but the data are too limited to conclude that intense sweeteners have a beneficial effect on lipid profile'.

'A cause and effect relationship has not been established between the consumption of foods and beverages in which sugars have been replaced by intense sweeteners and maintenance of normal blood glucose concentrations'.

'a cause and effect relationship has not been established between the consumption of foods and beverages in which sugars have been replaced by intense sweeteners and contribution to the maintenance or achievement of a normal body weight'.

'Randomised controlled trials conducted in adults indicate that increasing or decreasing the percentage of total dietary energy as sugars when consuming an ad libitum diet, either through the substitution of other macronutrient components or by replacing sugars with non-caloric sweeteners, leads to corresponding relative increases or decreases in energy intake'.

'Evidence from trials conducted in children and adolescents indicates that consumption of sugars-sweetened beverages, as compared with non-calorically sweetened beverages, results in greater weight gain and increases in body mass index, however the evidence is limited to a small number of studies'.

Replacing free sugars with non-nutritive sweeteners may reduce short term energy intake in the short-term, but their effectiveness remains to be evaluated as a strategy for weight management in the long term. There is a lack of research in children on the effects of non-nutritive sweeteners.

In most cases, the use of intense sweeteners as sugar substitutes 'results in a decrease in short-term energy intake due to their low calorie content and the lack of compensation. However, the available data cover insufficient time periods to guarantee the maintenance of this effect over the medium or long term'.

no conclusions can be drawn as to the long-term effect of replacing caloric sweeteners with intense sweeteners on the weight of regular adult consumers of sweet products. Similar for children and adolescents.

'Long-term observational studies conducted in children and adults provide inconsistent evidence of an association between low-calorie sweeteners and body weight, as compared to sugar-containing sweeteners'.

'Since the long-term effects of low-calorie sweeteners are still uncertain, those sweeteners should not be recommended for use as a primary replacement/substitute for added sugars in foods and beverages'.

Some data suggests that sweeteners 'may be used in a structured diet to replace sources of added sugars and that this substitution may result in modest energy intake reductions and weight loss'.

Non-caloric sweeteners, when used judiciously, 'could facilitate reductions in added sugars intake, thereby resulting in decreased total energy and weight loss/weight control, and promoting beneficial effects on related metabolic parameters. However, these potential benefits will not be fully realized if there is a compensatory increase in energy intake from other sources'.

moderate evidence of a beneficial effect of polyols on dental caries. Use of chewing gum containing polyols, compared to not using a chewing gum, is beneficial to oral health (mixed and permanent dentition).

insufficient/inconsistent evidence from RCTs on effects of polyols on caries of deciduous dentition, or of confectionary containing polyols on caries in mixed and permanent dentition.

not possible to determine the effect of regular intense sweetener consumption on sweetness habituation or increased cravings for sweetened products.

occasional consumption of intense sweeteners before or during a meal 'has no effect on food intake or energy intake during the next meal'.

Occasional intense sweetener consumption before a meal 'reduces the sensation of hunger and the desire to eat, just like caloric sweeteners, but this effect is temporary and disappears before the start of the meal'.

for habituation to sweetness, intense sweetener consumption 'has not shown any effects in adults'. However, in children, there are no data that demonstrate whether intense sweeteners have an effect on taste development, food preferences or the control of food intake.

Limited evidence that consumption of some polyols increases faecal weight, mass and affects faecal bacterial content (e.g. Bifidobacterium spp.). The health impact of an effect on faecal bacteria is currently uncertain, thus, whether this observation is beneficial or biologically relevant cannot be determined. No effects on faecal pH, faecal short chain fatty acids, based on limited evidence.

insufficient/inconsistent evidence on effects of polyols on intestinal transit time and constipation

Seeing the potential health implications of sugars consumption, major nutrition and health-related organisations have issued nutritional recommendations on limiting sugars and sugar containing foods and beverages (Table 6). Most refer to added or free sugars intake and target specifically sugar-rich products such as SSBs. Some recommendations set an upper limit of daily energy (calorie) intake of (added/free) sugars, which is in most cases 10% and sometimes 5% of the total daily energy intake (E%). Similarly, food based dietary guidelines generally recommend limiting sugars and sweetened products.

Table 6: Dietary recommendations for sugars intake as described by food- and health-related organisations

Available evidence not sufficient to set an upper limit for intake of added sugars.

Nevertheless, evidence of effects on weight gain, dental caries and micronutrient intake should be considered when establishing nutrient goals for populations, recommendations for individuals and food-based dietary guidelines.

'Intakes of free sugars should be reduced and minimised with a desirable upper limit of <5% energy intake in children and adolescents aged ≥ 2–18 years. Intakes should be even lower in infants and toddlers <2 years'.

'Smoothies and sweetened milk drinks/products (ie, milk products containing a higher concentration of sugars than unprocessed human, cow or goat milk, such as chocolate milks, condensed milks, fruit yoghurts) are an important source of free sugars and their intake should be limited'.

'Sugar-containing beverages and foods (SSBs, fruit juices, fruit based smoothies and sweetened milk drinks/products) should be replaced by water or, in the latter case, with unsweetened milk drinks/products with lactose up to the amount naturally present in milk and unsweetened milk products'.

'a recommendation focusing only on intakes of 'added' sugars is not justified…the available data cannot be used to distinguish the health effects of sugars naturally present in food from those of added sugars'.

'there is a range of evidence converging towards the harmful effects of high sugar intakes which makes it necessary to issue recommendations limiting sugar intakes in the population. The data currently available cannot be used to precisely establish the threshold of total sugars from which these effects appear.

It is however, necessary to propose an upper limit: 'of 100 g/day for total consumption of sugars, excluding lactose and galactose. This limit applies to the general healthy adult population, and to total sugars, whether they are naturally present in food or added during food manufacture or preparation.

'this value represents an upper intake limit not to be exceeded, and not an intake recommendation'a.

For young children (< 2 yrs. of age), 'because there is minimal room for nutrient-free calories in the habitual diets', added sugars should be avoided.

Recommendations for children and adolescents: reduce the intake of added sugars, including sugar sweetened beverages, juices and foods. It is recommended that children and adolescents limit intake of SSBs to 1 or fewer 8-oz (approx. 237 ml) beverages per week. It is also reasonable to recommend that children and adolescents consume less than 25 g (100 cal or approx. 6 teaspoons) of added sugars per day.

American women and men should not drink or eat more than 100 and 150 calories per day respectively from added sugars (6 and 9 teaspoons respectively).

Food based dietary guidelines from several of the WHO European Region countries recommend limiting sugar consumption from foods and beverages; several recommend choosing low-sugar or sugaring free alternatives.

a the proposed limit is based on fructose content of sugars; see reference for a detailed explanation on how this was calculated

Under EU law, sweeteners are food additives, and therefore their intake is considered under the scope of Acceptable Daily Intake (ADI) values. EFSA, and before that the Scientific Committee on Food, has set EU ADI values for both intense sweeteners and polyols, reported in Table 7.

In the EU, EFSA reported (EFSA 2010a) compiled data on carbohydrate intakes, drawn from national food consumption surveys, conducted from 1994 onwards, as well as from data in the ENHR report of 2009 (ENHR 2009). Due to differences in the methodology used to assess individual intakes and the different time points analysed, EFSA notes that the quality and quantity of data varies making direct comparisons difficult.

In the dataset compiled by EFSA, most countries did not report intakes of mono- or disaccharides separately. In the few countries that didi, average intakes of mono- and disaccharides varied from 23 to 36 E% in children and adolescents, and from 17 to 26 E% in adults. Additionally, some countries specifically reportedj average sucrose intakes, which varied between 6 and 14 %E in adults. Average intakes below 11 E% were only observed in the age categories of 35-64 y (94% of the group) and over 65 y (79% of the group). As EFSA noted, added sugars intake in some EU MS exceeded the 10 E% threshold recommended by WHO as well as national EU authorities, especially in children.

Data from other surveys on sugar intake can be found in Table 8; as before, due to differences in methodology, year of study, age groups involved, and measurement taken (e.g. total sugars or added sugars) it is difficult to draw any conclusions on the intake of added sugars across the EU.

Table 8: Overview of sugars intake across European countries (EU and Norway)

Intakes represent total intake from all sources, except where otherwise stated. Reported intake is based on publicly available data compiled by Prof. I. Elmadfa and Dr. Alexa Meyer (University of Vienna), unless referenced otherwise. Data may not be comparable due to differences in methodology, year of study, age groups involved, and measurement taken.

Acceptable Daily Intake (ADI) values have been already discussed in section 3.5 of the present Brief. In most cases, and as indicated in the relevant safety evaluations, even with high consumption scenarios, sweetener intake levels are expected to remain below the ADI threshold (ANSES 2015) .

As described in Table 4, high intake of added sugars can be a risk factor for ill health, especially in the case of intake of sugar sweetened beverages. For example, the Global Burden of Disease 2016 (GBD study 2016) study estimated that diets high in SSBs, defined as consumption of any beverage with more than 50 calories from sugar per a serving of one cupl, and including carbonated beverages, sodas, energy drinks, fruit drinks but excluding 100% fruit and vegetable juices, resulted in 3757 avoidable deaths in 2016 in the EU, as well as in more than 98.800 Disability Adjusted Life years (DALYs – sum of years lost due to premature death and years lived with disability), 36.050 Years Lived with Disability (YLDs – years of life lived with any short- or long-term health loss) and more than 62.700 Years of Life Lost (YLLs) due to premature mortality (GBD results tool).

A number of scientific associations, institutions and authorities have issued policy recommendations that ultimately aim to reduce intake of sugars, with a special focus on recommendations for children. These policy recommendations can be generally categorised in actions that i) tackle provision of information to the consumers, e.g. labelling of sugar content in foods, restrictions of marketing practices for foods high in sugars content, encouraging healthy behaviours such as drinking water, ii) making the healthy option available by improving the 'food environment', e.g. offering freely available water and limiting the availability of foods and beverages high in sugars content in schools or public environments, reformulating processed foods to reduce sugars content, and iii) implementing financial (dis)incentives such as taxes on products with high sugars content to dissuade consumers from purchasing or consuming them. A summary of such policy recommendations can be found in Table 9.

'given the limited effectiveness of charters on voluntary decreases, consider the establishment of regulatory measures targeting the main vectors of added sugars'.

'limit the availability of sweetened products in automatic vending machines and in particular in all places of education and teaching (primary and secondary schools, higher education facilities, universities, etc.)'.

Develop measures to reduce intake of free sugars through various public health interventions such as fiscal policies targeting foods and beverages high in free sugar.

'There is reasonable and increasing evidence that appropriately designed taxes on sugar-sweetened beverages would result in proportional reductions in consumption, especially if aimed at raising the retail price by 20% or more'.

'Legislation restricting marketing aimed at children of foods that are high in fats, sugar and/or salt, less healthy options, junk foods, drinks with alcohol and non-alcoholic beverages rich in sugar (e.g. on TV, internet, social media and on food packages) is recommended'.

Develop measures to reduce intake of free sugars through various public health interventions such as labelling, consumer education,

WHO proposes nutrient profile criteria for restricting marketing of foods to children, establishing limits (g/100 g), per food category for total and added sugars; if these limits are exceeded in a food product, its marketing to children should not be permitted.

Include information on free sugars on the nutrition information of food labelling, expressed both in grams and as % daily energy intake. A more practical way might be to add number of teaspoons of total sugars and free sugars on front-of-pack labels. 'However, further research testing consumer preferences and understanding is required'.

'raise the awareness of the population about the health effects of sugars, from a very early age, through information campaigns; the emphasis should be on nutritional education provided in schools; children should learn to identify the products that are vectors of sugars and to limit them as part of a varied diet'.

'make it mandatory to provide composition data on added sugars in manufactured products'.

The aim of this paragraph is to present examples of policies that are already in place to address sugars overconsumption. Similar to policy recommendations, most of these can be broadly categorised in policies that aim to provide information, make the healthy option available, or provide financial (dis)incentives to sugar consumption. Governments around the world have adopted different measures to reduce sugar consumption (Table 10), from the introduction of 'sugar taxes', to voluntary actions involving co-operation with relevant stakeholders, e.g. the voluntary reformulation pledges of the members of the EU Platform for Action on Diet, Physical Activity and Health. As in Table 10, many of the implemented policies target consumption of SSBs and limit the availability of sugary foods and beverages in schools.

Various EU countries' school food policies include voluntary or mandatory standards that limit or forbid provision of foods or beverages high in sugars in school restaurants, canteens. Some school food policies specify upper limits for total daily energy from sugars (commonly ≤10 E%).

The EU fruit, vegetable and milk scheme, financed through the EU's Common Agricultural Policy provides fruit, vegetables and milk to children in schools to increase their consumption. Among the criteria established for the products to be distributed to schools is that these should have no added sugars. Products containing limited quantities of sugars may be allowed if authorised by the relevant national health/nutrition authorities (DG AGRI).

The Healthy, Hunger Free Kids Act set standards for the national school lunch and breakfast programmes, which included limits on added sugars in foods and beverages. For example, Smart Snack standards limited sugar content of snacks or of main course meals to maximum of 35% by weight.

Scottish government guidelines for NHS hospital settings include removal of all soft drinks with >0.5g/100 ml of sugar, excluding pure fruit juice, and require that at least 30% of snacks and confectionaries and 70% of refrigerated food, meet nutrition criteria based on, among others, sugar content.

Bermuda

All food and beverages in vending machines on government premises meet nutrition criteria based on, among others, content of sugar. Criteria not applied to 100% fruit juices.

Social support programmes

US

San Bernardino County (CA) Healthy Food Banking Wellness policy has procurement guidelines which include unsweetened dairy products, unsweetened milk or milk substitutes, as well as canned fruits with no added sugars.

To stimulate reformulation over time, the 30 € cents/L will be gradually applied; in 2018, only to products with more than 10 g/100 ml of sugar, and then the limit will be reduced to 9 g/100 ml in 2019 and finally to 8 g/100 ml in 2020.

Sweetened milks and 100% fruit juice drinks could be freed from the tax, since Estonia will ask permission to give them state aid from the European Commission.

Since January 2017, prohibition of unlimited supply, for free or for a fixed price, of drinks with added sugars or synthetic sweeteners in all catering establishments open to the public, including hotels, holiday clubs, reception establishments, establishments training and housing minors (e.g. schools).

Norway

In Norway, a tax of 20.19 Kr (2.10€) /Kg applies to chocolate and sugar products, while sugar is taxed at 7.81 Kr (0.85€) /Kg.

Excise duties exist since 2011 on sweets, chocolate and non-alcoholic beverages. For sweets and ice cream the tax is 0.95€/Kg. On beverages with more than 0.5% of sugar, the excise tax is 0.22€/L, while for sweetener-based soft drinks and waters it is 0.11€/L on. Producers with an annual production volume of less than 50,000 L are exempt. The tax on sweets was abolished in January 2017, while the beverage tax remains in place.

Tax applying variable rates on salt, sugar, caffeine content of various ready to eat food categories, including soft drinks (with sugar or sweeteners). Tax amounts to 0.02 €/L for products with more than 8 g/100ml of added sugars, exempting drinks with more than 25% fruit or vegetable content or at least 50% of milk. Added sugar in confectionary is taxed at 0.22 €/L for products with sugar content >25%, while for chocolate the threshold is at 40% of total sugars.

Import duties

Pacific Ocean Island States

Import duties on soft drinks or sugar, ad valorem or per litre of product.

The EU Platform on Diet, Physical Activity and Health (EU platform) is a European Commission led and co-ordinated forum for EU stakeholder organisations, ranging from industry to consumer protection and NGOs that are voluntarily committing to tackle current trends in unhealthy diets and lack of physical activity. Various private food sector commitments are aimed to reformulate packaged foods and improve their nutritional profile by reducing, among others, sugars (EC 2015) .

The 2016 Dutch Presidency Roadmap for Action on Food Product Improvement, endorsed by the majority of EU MS as well as food business operators and some NGOs, aims to facilitate industry reformulation efforts by accelerating coordinated action from national governments, food business operators and NGOs, supported by sound research, independent monitoring and best practice exchange.

The EU framework for national initiatives on selected nutrients (EU framework) aims to contribute towards achieving population intake levels and dietary patterns recommended by national authorities, EFSA and WHO. Selected nutrients refer to a complex set of variables that may vary nationally and include, among others, total fat, SFA and TFA. The framework builds on five key principles of action: Data on intakes, benchmarks & major food categories to focus on, reformulation and changing portion sizes, raising public awareness, as well as monitoring and evaluating. Annex II (EU framework annex) is specifically addressed to added sugars:

Annex II is meant as a tool for the benefit and voluntary use of the MS, and can support them in designing, implementing and evaluating reformulation strategies in the context of their public health policies on nutrition-related NCDs.

Annex II suggests major food categories where action should be focused (e.g. SSBs, breakfast cereals, confectionary) and calls on MS to define their own priorities based on their respective health needs, traditions and consumption patterns

A proposed benchmark is a reduction of a minimum of 10% of added sugarsm in food products by 2020, compared to 2015 levels, or to move towards 'best in class levels', i.e. lowest levels identified in products of the same category in the EU.

Switzerland

'ActionSante' program includes voluntary agreement between the food industry and the ministry of health to among others, sugar content in bread and processed foods.

Food marketing restrictions

EU

Various mandatory (via legislation) or voluntary (via industry self-regulation) policies are in place in the EU to restrict food marketing of foods that are high in sugar, salt and fats to children; a major industry self-regulation effort is the EU Pledge. See the Food and non-alcoholic Beverage Marketing to children and adolescents in this series.

US

In the US, the Children's Food and Beverage advertising initiative is a major industry self-regulatory effort to restrict marketing of foods that are high in sugar, salt and fats to children. See the Food and non-alcoholic Beverage Marketing to children and adolescents in this series.

Retail initiatives

US

In New York, department of health staff collaborate with shop owners in areas with high rates of obesity, to make foods such as, canned products, dried fruits and nuts with no added sugar available in food stores.

The 2016 Nutrition Facts Label US regulation revision introduces the requirement for declaration of amount of total sugars; in addition added sugars should also be declared, in grams in a serving of a product, establishing a DRV and requiring the percent of daily value declaration.

The Keyhole health logo labelling system by the Swedish National Food Agency is used in Scandinavian countries. It is based on a nutrient profile model and aims to identify healthier packaged food choices within a food category, and to stimulate food manufacturers to reformulate and develop healthier products. Sugar content is one of the nutrient criteria, and thresholds depend on the product category.

'Healthy Living' is a voluntary labelling scheme with nutrient profiles for different food categories. The scheme is used as a benchmark for public health campaigns but also as a scientific basis for a national initiative on food marketing restraints. Sugar is one of the nutrients to limit in this scheme.

The Health Star Rating (HSR) is a front-of-pack voluntary labelling scheme. The system is based on an algorithm that awards a star rating, based on the quantity of specific food components, such as total sugars.

Various countries

Various other voluntary systems include sugars in their labelling criteria e.g. traffic light/ colour coding systems in Ecuador and South Korea for total sugars, Heart Check in Nigeria for added sugars.

The Change4Life campaign aims to improve diets and physical activity in the UK; Smart Swaps and Sugar Smart are major components aimed at reducing sugar consumption and provide examples of how this can be achieved

Recommendation & guidelines

EU

Nutrition recommendations and food based dietary guidelines in all EU MS states recommend limiting sugar intake. See Paragraph 3.5.

The EU fruit and vegetable and milk scheme, financed through the EU's Common Agricultural Policy, provides fruit, vegetables and milk to children in schools, in order to increase increase their consumption. Among the criteria established, the products to be distributed to schools must not contain sweeteners or artificial flavour enhancers (DG AGRI, EU 2016).

Tax applying on various rates on salt, sugar, caffeine content of various ready to eat food categories, including soft drinks (both with sugar or sweeteners). The soft drink tax amounts to 0.02 €/L for products with more than 8 g/100ml of added sugars, excepting drinks with more than 25% fruit or vegetable content or at least 50% of milk.

Sweeteners are not allowed in Keyhole products. The Keyhole health logo labelling system by the Swedish National Food Agency is used in Scandinavian countries. It is based on a nutrient profile model and aims to identify healthier packaged food choices within a food category, and to stimulate food manufacturers to reformulate and develop healthier products.

The UK Eatwell guide is a policy tool from Public Health England to define goverment recommendations on healty eating. Concerning sugar reduction the guide states that 'If you add sugar to your food or drinks, gradually reduce the amount you add until your taste buds adapt and you can cut it out altogether. Alternatively try using a calorie free sweetener instead.'

aIn this table the terminology used to refer to sweeteners is as given in the literature source (e.g. artificial sweeteners), and may not coincide with the term adopted for the purposes of this brief.

d. Although the Joint FAO/WHO Expert Consultation report (1998) includes polyols as sugars, this is due to a chemical classification; in this guide polyols are addressed separately from sugars, due to their different nutritional and functional properties following EFSA, the SACN report (2015) and the approach of Reg. (EC) 1333/2008 and Reg. (EU) 1169/2011

e. Reg. 1333/2008 also includes a third category: 'producing food intended for particular nutritional uses as defined in Article 1(2)(a) of Directive 89/398/EEC'. However, the 89/398/EEC directive has been repealed by Reg. (EU) 609/2013, which defines a list of substances that can be added to food intended for infants and young children, foods for special medical purposes, and foods for total diet replacement for weight control. Currently (Oct 2017), no sweetener is included in that list.

f. Some intense sweeteners contain calories. Even so, being much sweeter than sucrose, they are used in small amounts and therefore their overall energy contribution to the final product is very small.

h. Conditional recommendations are made when there is less certainty about the balance between the benefits and harms or disadvantages of implementing a recommendation. This means that policy-making will require substantial debate and involvement of various stakeholders for translating them into action. WHO handbook for guideline development (2014) 2nd edition

i. For children and adolescents: NL, BE in the 1-3 y age group; BE, SE in the 4-6 y age group; NL, SE in the 7-9 y age group, BE, NL, SE for the 10-14 y age group; NL for the 15-18 y age group. For adults: BE, ES, SE for the 19-65 y age group; NL for the 19-34 y age group; DE for the 35-64 y age group

j. AT, DK, FI, HU, LT, NO, PL, SE in the 19-65 y age group; DK, SE in the 19-34 y age group; DE, DK, SE in the 35-64 y age group

k.As EFSA notes, given that EFSAs opinion on steviol glycosides indicated high consumers might exceed the established ADI value, the Commission may ask EFSA to perform a new exposure assessment, as data from the use of steviol glycosides become available.

l. There is no universal definition of a 'cup'. In the US Legislation, for the purposes of nutrition labelling, 1 cup equals 240 ml

m. For the scope of Annex II, the term added sugars goes beyond the EFSA definition of the term, and 'is additionally considered to include sugars present in honey, syrups, and fruit juices and fruit juice concentrates. This is the case because, for reformulation purposes, they can be described as providing energy while not significantly contributing other nutrients to foods.'